Ryan White Part B HIV/AIDS Medical and Non-Medical Case ... and Non... · with HIV/AIDS out of...

Case Management Standards

Last Revised 4/10/2018 of 55

Georgia Department of Public Health

Division of Health Protection

Office of HIV/AIDS

Ryan White Part B HIV/AIDS

Medical and Non-Medical


April 1, 2018 – March 31, 2019



Contents

I. Introduction…………………….….……….……………………..……..…………….. 3

II. Background…………..…….…….………….………...….………………...….........… 3

III. Section 1: Case Management Defined……...……………….………..……………… 4

• The Case Manager….……..………..………………..………………………. 5

• Table 1: Case Management Personnel….……………….………...…………. 7

• Agency Policy and Procedures…………………………………..……...…… 8

• Table 2: Agency Policy and Procedures………………..……………..…….. 9

IV. Section 2: Intake Overview...…………………………………………….………….. 10

V. Section 3: Initial Intake………..………………..………………………….............… 11

• Table 3: Intake…………………………….……………….……...……….…. 13

VI. Section 4: Acuity Scale………………………………………..…………….………… 14

• Table 4: Acuity Scale…………..…………………………....……..……..….. 16

VII. Section 5: Individualized Service Plan (ISP)………….………….…………………. 16

• Table 5: ISP Assessment ……..…………………………....……..……..….. 19

• Coordination of Care and Re-evaluating ISP….……………………………… 19

• Table 6: Coordination of Services…..…………..……….…………………... 20

• Table 7: Re-evaluating the ISP…………………………………………..…... 21

• Table 8: Transition and Discharge…..……………………………………….. 22

VIII. Section 6: Documentation………………………….………….……………………… 22

• Table 9: Documentation………..…………………………....……..………… 25

Appendices……………………………………………………………….……………. 26

A. Client Intake………………….……………….……………………………… 27

B. 2018 Income Expense Spreadsheet………..………………………………... 34

C. Case Management Acuity Scale…………….………….….………………… 36

D. Individualized Service Plan (ISP)……………….……….………..…………. 43

E. Activities by Acuity Levels………………………….……………………..… 49

F. Georgia Case Management Definitions ………………..…………….…….... 52

G. Request to Receive ADAP/HICP Only………..……………….…………….. 54



Introduction

HIV/AIDS case management provides a system of case management based upon the changing

needs of enrolled clients. Medical and Non-Medical Case management in Georgia is available

statewide through Ryan White HIV/AIDS Programs that receive federal funds from the Health

Resources and Services Administration (HRSA). Funded case managers in the state also provide

referrals to support services such as transportation, housing, food banks, etc. Clients who receive

any Ryan White Part B funded service should be enrolled in Case Management.

The purpose of the Georgia HIV/AIDS Case Management Standards is to provide guidance to

funded agencies and case managers that will assist in fulfilling the Ryan White Part B Office of

HIV/AIDS minimum expectations for case management. These Standards are not meant to

replace or override existing, more detailed standards that provider agencies may already have in

place. If any agency is unable to meet case management standards, there must be documentation

explaining why they were unable to meet the standards. The Standards are intended to assist the

agency and case managers in fulfilling the following goals of case management:

• To increase the quality of care and quality of life for persons living with

HIV/AIDS

• To improve service coordination, access and delivery

• To reduce the cost of care through coordinated services which keep persons living

with HIV/AIDS out of urgent care centers, emergency rooms and hospitals

• To provide client advocacy and crisis intervention services

Background

The HIV services system provides several types of coordination, referral, and follow-up services

that eliminate barriers and help people with HIV get connected and stay in care. Medical Case

Management (MCM) is the backbone of the HIV services delivery system and the primary way

of ensuring that people with HIV access, receive, and stay in primary medical care. MCM assess

the primary and immediate needs of people with HIV, coordinate referrals, and follow-up with

critical core medical and support services to ensure people with HIV remain in medical care. The

services that are provided are in alignment with the National HIV/AIDS Strategy and focus on

entry into care, retention in care and viral load suppression.

The continuum of interventions that begins with outreach and testing, and concludes with HIV

viral load suppression is generally referred to as the HIV Care Continuum or the HIV Treatment

Cascade. The HIV Care Continuum includes the diagnosis of HIV, linkage to primary care,

lifelong retention in primary care, appropriate prescription of antiretroviral therapy (ART), and

ultimately HIV viral load suppression.



Sub-recipients are encouraged to assess the outcomes of their programs along the HIV Care

Continuum. Funded agencies should work with their community and public health partners to

improve outcomes across the Continuum, so that individuals diagnosed with HIV are linked and

engaged in care, and started on ART as early as possible.

Section 1: Case Management Defined

Case management is a directed program of care and social service coordination. Typically,

clients are enrolled into case management to ensure a more comprehensive continuum of care, if

needed. They are also enrolled if they exhibit a need to navigate coordination with services that

provide assistance with obtaining social, community, legal, financial and other needed services,

as well as follow-up to medical treatment. There are many definitions that vary among agencies;

however, the definition of case management used will be that from HRSA PCN #16-02 for Ryan

White Programs:

Medical Case Management, including Treatment Adherence Services: Medical Case

Management is the provision of a range of client-centered activities focused on improving health

outcomes in support of the HIV care continuum. Activities may be prescribed by an

interdisciplinary team that includes other specialty care providers. Medical Case Management

includes all types of case management encounters (e.g., face-to-face, phone contact, and any

other forms of communication). Key activities include:

• Initial assessment of service needs

• Development of a comprehensive, individualized care plan

• Timely and coordinated access to medically appropriate levels of health and

support services and continuity of care

• Continuous client monitoring to assess the efficacy of the care plan

• Re-evaluation of the care plan at least every 6 months with adaptations as

necessary

• Ongoing assessment of the client’s and other key family members’ needs and

personal support systems

• Treatment adherence counseling to ensure readiness for the adherence to complex

HIV treatments

• Client-specific advocacy and/or review of utilization of services

In addition to providing the medically oriented services above, Medical Case Management may

also provide benefits counseling by assisting eligible clients in obtaining access to other public

and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State

Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs,

other state or local health care and supportive services, and insurances plans through the health

insurance Marketplace/Exchanges).

Medical Case Management services have as their objective improving health care outcomes,

whereas Non-Medical Case Management Services have as their objective providing guidance

and assistance in improving access to needed services.

https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf



Visits to ensure readiness for, and adherence to, complex HIV treatments shall be considered

Medical Case Management or Outpatient/Ambulatory Health Services. Treatment Adherence

Services provided during a Medical Case Management visit should be reported in the Medical

Case Management service category whereas Treatment Adherence services provided during an

Outpatient/Ambulatory Health Service visit should be reported under the Outpatient/Ambulatory

Health Services category.

Non-Medical Case Management Services: Non-Medical Case Management Services (NMCM)

provide guidance and assistance in accessing medical, social, community, legal, financial, and

other needed services. Non-Medical Case Management services may also include assisting

eligible clients to obtain access to other public and private programs for which they may be

eligible, such as Medicaid, Medicare Part D, State Pharmacy Assistance Programs,

Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local healthcare and

supportive services, or health insurance Marketplace plans. This service category includes

several methods of communication including face-to-face, phone contact, and any other forms of

communication deemed appropriate by the RWHAP Part recipient. Key activities include:





necessary



Non-Medical Case Management Services have as their objective providing guidance and

assistance in improving access to needed services whereas Medical Case Management services

have as their objective improving health care outcomes.

The Case Manager Roles of a Case Manager

The roles of the case manager are varied and require that case managers assist clients in

addressing problems in all facets of their lives. Case managers often act in, but are not limited to

the following roles:

• Advocate

• Counselor

• Problem Solver

• Coordinator with Service Providers

• Planner

• Prudent Purchaser

Skills of a Case Manager

In addition to requiring that staff be knowledgeable in all areas listed above, case managers must

possess a wide range of skills in order to carry out their functions. The case manager must have

considerable skills in locating, developing, and coordinating the provision of supportive services

in the community, as well as skills in coordination and follow-up of medical treatments and



adherence counseling. Case managers can benefit from training in the following areas regardless

of their educational background:

• Case management process (Intake, Assessment, Care Plan Development and

Implementation, Coordination of Services, Monitoring/Re-evaluation, and

Documentation)

• Interviewing

• Oral, written, and communication skills

• Establishing rapport and maintaining relationships

• Knowledge of eligibility requirements for applicable local, state and federal

programs

• Community organizations

• Consultation strategies

• Basic working knowledge of HIV/AIDS

• Basic understanding of highly active antiretroviral therapy (HAART) including

treatment adherence

• Record keeping and documentation

• Knowledge regarding the current standards of HIV/AIDS care and case

management processes

All staff should be provided opportunities for training to become familiar with the particular

aspects of HIV/AIDS to better understand the needs of the clients served. Case managers should

be provided an opportunity for training in all aspects of the disease including coordination and

follow-up of medical treatments and the provision of treatment adherence counseling.

Publications and newsletters relating to HIV/AIDS can provide informative reading material for

case managers. All case managers need to be trained in the use of state approved forms and

methods of documentation.

Caseload Size

Caseload size is one of the most important factors affecting job performance. Generally, a

caseload of up to 1:75 is considered optimum for the reasons stated above, but few case

management agencies have caseloads at this level. Limiting caseload below 75 clients is

encouraged, but caseloads are generally 75 or above. When caseloads increase above 75 clients,

the nature of the case manager’s role may change in the following ways:

• Interactions with clients can become reactive rather than proactive

• More demanding clients may receive the greatest amount of attention from the

case manager

• Case managers may not have enough time to develop a suitable rapport with the

client

• To save time, case managers may do more for clients rather than working with the

clients to foster their independence

• Lastly, more time will be spent on documentation requirements, data collection

and reporting

• Staff turnover may increase secondary to burnout



Caseload size alone is not necessarily indicative of the case manager’s workload. The stage of

the client’s illness and/or the emergency circumstances which a client may or may not have (i.e.,

housing needs) often dictates how a case manager’s time is spent. Case managers should be

assigned caseloads in a number of ways including caseload number, specialization of cases, level

of acuity, and client’s geographic location. Funding source is another criteria used to assign

cases. Case management programs should establish a fair method of assigning caseloads based

on the unique make-up of the HIV/AIDS population in their service area.

Table 1. Case Management Personnel

Standard Measure

1.1 Newly hired HIV case managers will have the following minimum

qualifications:

• The appropriate skill set and relevant experience to provide

effective case management, as well as, be knowledgeable

about HIV/AIDS and current resources available.

• The ability to complete documentation required by the case

management position.

• Have a Bachelor’s Degree in a Social Science or be a

Registered Nurse with at least one year of Case Management

experience. One year of full-time (or equivalent part-time)

work experience in social services delivery (case

management, outreach, prevention/education, etc.).

Resume in personnel file.

1.2 Newly hired or promoted HIV Case Manager Supervisors will have

at least the minimum qualifications described above for case

managers plus two years of case management experience, or other

experience relevant to the position (e.g., volunteer management

experience).

Resume in personnel file.

1.3 Case management provider organizations will give a written job

description to all case managers and all case manager supervisors.

Written job description on file

1.4 Case managers will comply with the Georgia HIV/AIDS Case

Management Standards.

Review of case management

records.

1.5 Case managers will receive at least two hours of supervision per

month to include client care, case manager job performance, and

skill development.

Documentation in personnel

file of case manager job

performance.

1.6 The optimum caseload per case manager is up to 75 active clients. Observations during site visit

and self-report by case

manager.

1.7 Case managers will receive training on the Case Management

Standards and standardized forms.

Documentation in training

records/personnel file.



1.8 Case managers will participate in at least six (6) hours of

education/training annually.

Documentation in training

records/personnel file.

1.9 Each agency will have a case management supervision policy. Written policy on file at

provider agency.

1.10 Each agency must maintain the Case Managers credentials and/or

evidence of training of health care staff providing case

management services.

Documentation of credentials

in records/personnel file.

Agency Policy and Procedures

The objective of the policies and procedures standard is to ensure that agencies have policies and

procedures in place that:

• Establish client eligibility

• Guarantee client confidentiality

• Define client rights and responsibilities

• Outline a process to address client grievances

• Uphold Health Insurance Portability and Accountability Act (HIPAA) policy

Eligibility Policy

Agencies must establish client eligibility policies that comply with state and federal regulations.

These include screenings of clients to determine eligibility for services within 15-30 days of

Intake. Agencies must have documentation of eligibility in client’s records including proof of

HIV/AIDS positive medical diagnosis, must be a Georgia resident, income at or below 400% of

the Federal Poverty Level (FPL) and must have no other payer source for the services provided.

Confidentiality Policy

A confidentiality policy protects client’s personal and medical information such as HIV status,

behavioral risk factors, and use of services. The confidentiality policy must include consent for

release of information and storage of client’s records.

Client Right and Responsibilities Policy

Active participation in one’s health care and sharing in health care decisions maximizes the

quality of care and quality of life for people living with HIV/AIDS. Case Managers can facilitate

this by ensuring that clients are aware of and understand their rights and responsibilities.

Grievance Policy

An agency’s grievance policy must outline a client’s options if he or she feels that the case

manager or agency is treating him or her unfairly or not providing quality services. The

grievance procedure must be posted and visible to clients.

Health Insurance Portability and Accountability Act (HIPAA)

An agency must provide the client with the agency’s Notice of Privacy Practices on the first date

of service delivery as required by the Health Insurance Portability and Accountability Act of



1996 (HIPAA). Obtain a signed copy of the patient acknowledgement of Notice of Privacy

Statement (HIPAA form). Provide the client with a copy of the signed statement.

Table 2. Agency Policy and Procedures

Standard Measure

2.1 Each agency must have an eligibility policy and

procedure that comply with state and federal regulations

(i.e., linguistically appropriate for the population being

served)

Written policy on file at provider agency.

2.2 Each agency must have a client confidentiality policy

(i.e., linguistically appropriate for the population being

served). Every employee must sign a confidentiality

agreement.


Copy of signed confidentiality agreement

in personnel file.

2.3 Each agency must have grievance policies and

procedures; and client’s rights and responsibilities (i.e.,

linguistically appropriate for the population being

served).

Each agency must implement, maintain, and display

documentation regarding client’s grievance procedures and

client’s rights and responsibilities.


Grievance procedures and client’s rights

and responsibilities displayed in public

areas of the agency.

2.4 Inform the client of the client confidentiality policy,

grievance policies and procedures, and client’s rights

and responsibilities at Intake and annually.

The case manager and client will sign documentation of the

above. The case manager will provide the client with copies

of the signed documents.

Documentation in the client’s record

indicating that the client has been

informed of the confidentiality policy,

grievance policies and procedures and

client’s rights and responsibilities.

Signed documentation in client’s record.

2.5 Obtain written authorization to release information for

each specific request. Each request must be signed by

the client or legal guardian. (e.g., linguistically

appropriate for the population being served)

Note: If releasing AIDS Confidential Information (ACI), the

client must sign an authorization for release of information,

which specifically allows release of ACI. (See Georgia Code

Section 24-9-47 for medical release of ACI.)

Release of information forms signed by

client in case management record.

2.6 Provide the client with the agency’s Notice of Privacy

Practices on the first date of service delivery as required

by the Health Insurance Portability and Accountability

Act of 1996 (HIPAA). Obtain a signed copy of the

patient acknowledgement of Notice of Privacy

Statement (HIPAA form). Provide the client with a copy

of the signed statement.

Signed acknowledgement of Notice of

Privacy Statement (HIPAA form) in the

client’s record.

https://law.justia.com/codes/georgia/2010/title-24/chapter-9/article-2/part-2/24-9-47/




Section 2: Intake Overview

The purpose of the Intake process is to ensure the client understands what medical case

management is and that the client is currently not receiving this service elsewhere. It is

extremely important to provide mandated information and obtain required consents, releases, and

disclosure. An Intake is also a time to gather and provide basic information from the client with

care and compassion. It is also a pivotal moment to establish trust, confidence, and rapport with

the client. If there is an indication that the client may be facing an imminent loss of medication

or other forms of medical crisis, the Intake process should be expedited and appropriate

intervention should take place prior to formal enrollment.

Five steps must be completed for every client who is new or re-enrolling into case management:

Client Intake, Income/Expense Spreadsheet, Acuity Scale, Individualized Service Plan (ISP), and

case note documentation. The above-mentioned forms will be discussed in further detail

throughout this document.

1) Intake

The first step in the enrollment process is to complete the Client Intake form. Upon completing

this form, the case manager will review all documents to ensure that the requested information

has been provided, signed by both client and case manager and that all supporting documents are

attached. The Client Intake must be completed within 15-30 days of beginning the initial Intake

assessment depending on the client’s level of acuity. Additional information regarding the Client

Intake can be found on pages 11-13 and the Case Management Intake form is located in

Appendix A.

2) Income/Expense Spreadsheet

The second document to be completed is the Income/ Expense Spreadsheet. This document will

tabulate as numbers are entered into the cells. The purpose of this form is to obtain information

regarding a client’s financial expenses/resources. The Income/Expense Spreadsheet must be

completed within 15-30 days of beginning the initial Intake. The spreadsheet is located in

Appendix B.

3) Acuity Scale

The third step is to complete the Acuity Scale assessment. It is not necessary for a client to sign

this document, only the case manager. The scale is a tool for case managers that can be used in

conjunction with the initial Intake to develop an ISP. The Acuity Scale translates the assessment

into a level of support designed to provide assistance appropriate to the client’s assessed level of

functioning. This document must be completed within 15-30 days of beginning the initial Intake

depending on the level of acuity. Additional information regarding the Acuity Scale can be found

on pages 14-16 and the Case Management Acuity Scale is located in Appendix C.



4) Individualized Service Plan (ISP)

The fourth step is to develop the initial comprehensive ISP, which constitutes another essential

function of case management. The ISP is the “bridge” from the assessment phase to the actual

delivery of services. The primary goal of the ISP is to ensure client’s access, retention, and

adherence to primary medical care by removing barriers to care. A comprehensive assessment is

developed using information gathered while completing the Intake and Acuity Scale to determine

the level of client’s needs and personal support systems. The information is then used to develop

a mutually agreed upon comprehensive ISP with specific goals and action steps to address

barriers to care. The ISP’s should be developed using SMART objectives; Specific, Measurable,

Attainable, Realistic, and Time Specific. A comprehensive ISP should be signed by both the

client and case manager within 15-30 days of beginning the initial Intake process depending on

the level of acuity. Additional information regarding the ISP can be found on pages 16-21 and in

Appendix D.

5) Case Note Documentation

The final step is to complete a case note that contains specific details to explain information

gathered during the Intake process as well as other relevant information. Case note

documentation, regardless of complexity, must be comprehensive enough to support the design

and implementation of the ISP and the nature of case management services provided. A client's

history is usually reflective of trends and may offer valuable insight about what to expect in the

future. It is important that the case managers documentation reflects the following: subjective

(what you hear) and objective (what you see) observations (e.g. changes in health status or

feelings of anxiety or depression). Document any actions done in response to the observations

and the client's response to the actions. To provide a more complete picture of the client’s

situation, the case manager may document the client’s, family member or significant other’s

actual response (verbal or non-verbal) to any aspect of care provided. A verbal response may be

documented using quotations (e.g. “response” marks). Non-verbal responses should be described

in as much detail as possible. This case note documentation must be completed within 15-30

days of beginning the initial Intake. Additional information regarding case notes can be found on

pages 22-25.

Section 3: Initial Intake

The case manager should become familiar with the eligibility requirements of numerous

assistance programs to better meet the needs of the client. The Ryan White HIV/AIDS Program

requires that funds are utilized as the payer of last resort. The following eligibility documents

must be provided during intake: proof of HIV/AIDS positive medical diagnosis, proof of Georgia

residency, income at or below 400% of the Federal Poverty Level (FPL) and must have no other

payer source for the services provided.

An Intake is the formal process of collecting information to determine the client’s eligibility for

services and his/her immediate service needs. During the Intake, clients should be informed of

the case management services available that can assist them with maintaining their wellbeing and

independence. The information collected during the Intake process provides the basis for

obtaining an informed consent for case management services and for conducting the

comprehensive needs assessment.



The following are objectives of an Intake: establish rapport and trust between the client and case

manager, determine the client’s immediate need and link them to the appropriate resources,

inform the client of the scope of services offered by the Ryan White program including benefits

and limitations, inform the client of his/her rights and responsibilities as a participant in the

program, and obtain the client’s informed consent to participate in the program. Case managers

should allow the interactions with the client to evolve in such a way that the client feels free to

express his/her needs openly and for those needs to be acknowledged by the case manager.

An Intake must be completed for new or re-enrolling case management clients. The client should

serve as the primary source of information; a case manager should actively engage the client in

the assessment process. Clients may be asked to identify their own strengths/weaknesses and to

assist in identifying support services that will be needed for independent living. The healthcare

team may be contacted for more information regarding the client’s medical condition and

support services. Additional sources of information might include hospital or social service

agency records, family, friends, and therapists. These sources of information must be utilized

only with the knowledge and consent of the client. Five major areas of a client’s life for

consideration when conducting an Intake include the following:

1. Clinical/Medical – This includes discussion of the client’s health status, diagnosis,

possible treatments, the client’s right to refuse care or insist upon a different approach

and access to primary care.

2. Psychosocial – This includes discussion of the client’s level of coping or functioning and

past coping strategies that were tried. A review of available resources for client support,

an assessment of the client’s strengths/weaknesses, support groups and barriers to care

should also be addressed.

3. Social – This includes discussion of the client’s family structure, significant others and

cultural background. The case manager should meet with the client’s family members

and significant others, if the client wishes. The client’s history of family, friends, spouses,

domestic partners and others are essential to the client’s well-being. This network can

provide a range and depth of services which can only be enhanced.

4. Economic – This includes the current financial resources and insurance coverage, and

financial assistance that has not been explored (i.e., food, housing, transportation, etc.).

Budget counseling and debt management should be provided as an option. All resources

including but not limited to employment and disability coverage should be explored. The

client and family should be educated about insurance issues and terminology. (See

Appendix 2. Income/Expenses Form.)

5. Cultural – This includes assessing culturally specific needs of the client and ensuring that

case management services are provided in the preferred language of the client. Please

note that it is not encouraged to rely on children or family to interpret for the client.

Language assistance may be necessary to interpret and/or translate key information

including, but not limited to, the consent for services, consent for release of

medical/psychosocial information, grievance policy and any other similar documents that

a provider might typically use during service provision to clients.



Typically, the initial interaction with the client regarding case management services will occur

via face-to-face or telephone. However, the Intake can be conducted in other locations such as:

office, hospital, clinic, home, or shelters. The Intake is necessary to determine whether the client

is experiencing a crisis situation and/or requires an immediate referral. The case manager and

client will discuss services offered, the expectation from both client and case manager, and

requirements to access case management services. It is during this interaction that the case

manager and client establish the basis for developing rapport and trust, which are essential

elements of case management. This information must be discussed during the Intake in order to

avoid future miscommunication and inappropriate expectations.

If it is determined that the client is eligible for HIV/AIDS services the case manager or another

staff member should proceed with the following:

• Obtain consent for services based on agency’s policies

• Explain medical and support services available and other case management

procedures

• Explain the agency’s regular, after-hours, weekend, and holiday policies (if

applicable)

• Explain the agency’s grievance policy, policies/procedures and client rights and

responsibilities

• Advise client of his/her rights to confidentiality as specified by state statutes and

obtain authorization to release confidential information as needed

• Initiate a client file/record to be maintained throughout the duration of the client’s

involvement with the case management agency

Note: The client must sign an authorization for release of information, which specifically allows

release of AIDS Confidential Information (ACI). (See Georgia Code Section 24-9-47 for medical

release of ACI.)

Table 3. Intake

Standard Measure

3.1 Determine Ryan White Part B eligibility for

services.

Documentation of eligibility in client’s records

including proof of HIV/AIDS positive medical

diagnosis, proof of Georgia residency, income at

or below 400% of the Federal Poverty Level

(FPL) and must have no other payer source for

the services provided.

3.2 Obtain client’s authorization to obtain and/or

release information if there is an immediate

need to release or request information.

Signed Release (or No-Release) of Information in

client’s record.

3.3 Complete the Initial Intake, Income/Expense

Spreadsheet, Acuity Scale, initial ISP, and case

note within 15-30 days of beginning the initial

Intake assessment.

Completed Intake, Income/Expense Spreadsheet,

Acuity Scale, initial ISP, and case note in client’s

record.




Section 4: Acuity Scale

All new and re-enrolling clients must have an Acuity Scale completed. The scale is a tool for the

case managers to use in conjunction with the initial Intake to develop an Individualized Service

Plan (ISP). The intent is to provide a framework for documenting important assessment elements

and standardizing the key questions that should be asked as part of an assessment. This scale also

translates the assessment into a level of programmatic support designed to provide the client

assistance appropriate to their assessed need and function.

The case manager can at his/her discretion increase the acuity level based upon his/her

assessment and client needs, i.e., there are circumstances which indicate the client may benefit

from additional services or support. An assigned acuity level can be increased, but not

decreased. The acuity level can only be decreased after completing a new Acuity Scale, which

indicates a lower level of acuity than the previously dated Acuity Scale.

Acuity Levels

Level 1 and 2 clients are lower levels of acuity, which require less intensive case management

services. Level 3 clients are at a higher acuity level which require more case management

services. Level 4 clients are at the highest acuity level which require intensive case management

services. Appropriate case management activities are assigned in accordance with the Activities

by Acuity Level document according to the indicated acuity scale levels. Below are the Acuity

Levels, point values and a brief description of a client who has been assigned that level of acuity.

Level 1 Self-Management 16-17 points

Self-management is appropriate for clients who are adherent to medical care and treatment, are

independent, and are able to advocate for themselves. Clients may need occasional assistance

from the case manager to update eligibility forms. These clients have demonstrated capability of

managing self and disease, are independent, medically stable, virally suppressed and have no

problem getting access to HIV care. Additionally, their housing and income source(s) should be

stable. If clients have a mental health diagnosis, they should be in the care of a mental health

provider and adherent to their treatment plan. If clients have a history of substance abuse, they

should have more than 12 months of sobriety and should preferably be accessing continued

support services to maintain their sobriety. The majority of case management services provided

will be non-medical vs. medical. The objective is to provide guidance and assistance in

improving access to needed services. Revision of the acuity scale and ISP must occur at least

every 6 months with adaptations as necessary.

Level 2 Supportive 18-22 points

Supportive case management is appropriate for clients with needs that can be addressed in the

short term. Clients should be adherent to their medical care and treatment, independent, and able

to advocate for themselves. Additionally, these clients require minimal assistance and their

housing and income source(s) should be stable. Clients may require service provision assistance

no more that 2-3 times a year. If the clients have a mental health diagnosis, they should be in the

care of a mental health provider and adherent to their treatment plan. If clients have a history of

substance abuse, they should have no less than 6-12 months of sobriety and should preferably be

accessing continued support services to maintain their sobriety. This includes the provision of



advice and assistance in obtaining medical, social, community, legal, financial, and other needed

services. The majority of case management services provided will be non-medical vs. medical,

the objective is to provide guidance and assistance in improving access to needed services.

Revision of the acuity scale and ISP must occur at least every 6 months with adaptations as

necessary.

Level 3 Intermediate 23-37 points

Intermediate case management is appropriate for clients who are considered medically case

managed. Coordination and follow-up of medical treatment is a component of medical case

management. These clients require assistance to access and/or remain in care, and are at risk of

medication and appointment non-compliance. They may have opportunistic infections and other

co-morbidities that are not being treated or addressed and have no support system in place to

address related issues. The case manager should ensure timely and coordinated access to

medically appropriate levels of health and support services, and continuity of care, through

ongoing assessment of the client’s and other key family members’ needs and personal support

systems. Key activities include but are not limited to: completing initial Intake within 30 days of

beginning Intake, development of an individualized service plan (ISP) within 30 days of

beginning Intake, and re-evaluation of the acuity scale and ISP with a revision at least every 6

months. The majority of case management services provided will be medical vs. non-medical

and the objective is to improve health care outcomes. Documentation should be reflective of

goals, activities and outcomes in the case notes. Consultation with a multi-disciplinary team, case

management supervisor and/or others as needed should be documented.

Level 4 Intensive 38-56 points

Intensive case management is appropriate for clients who are considered medically case

managed. These clients require assistance to access and/or remain in care. The clients are at risk

of becoming lost to care and are considered medically unstable without MCM assistance to

ensure access and participation in the continuum of care. The case manager should ensure timely

and coordinated access to medically appropriate levels of health and support services, and

continuity of care, through ongoing assessment of the client’s and other key family members’

needs and personal support systems. Key activities include but are not limited to: completing

initial Intake within 15 days of beginning Intake, development of an individualized service plan

(ISP) within 30 days of beginning Intake, and re-evaluation of the acuity scale and ISP with a

revision at least every 3 months. The majority of case management services provided will be

medical vs. non-medical and the objective is to improve health care outcomes. Documentation

should be reflective of goals, activities and outcomes in the case notes. Consultation with a

multi-disciplinary team, case management supervisor and others as needed should be

documented.

Upon completing and scoring the Acuity Scale, the Activities by Acuity Level document in

Appendix 5 provides timelines and activities that must be followed depending on the acuity level

score. Information obtained while completing the Acuity Scale can be used to develop the ISP.

After the initial documents have been completed for a new or re-enrolling client, the next step is

to determine when the Acuity Scale and ISP will need to be revised. For level 4 clients, this will

be at least every 3 months. Level 1-3 clients, will require revision at least every 6 months.

However, the ISP and Acuity scale can be updated more frequently if needed.



Table 4. Acuity Scale

Standard Measure 4.1 All new or re-enrolling case management client

charts will have a completed Acuity Scale

within 15-30 days of initial assessment.

Acuity Scale must be assessed and a score

assigned and in the client chart.

4.2 All case managed client charts containing a

completed Acuity Scale will have a level of

acuity assigned.

Every Acuity Scale must contain the Total Score

and Assigned Acuity Level reflective on each

completed Acuity Scale Assessment and in the

client chart.

4.3 All Acuity Scale assessments will be updated

in accordance with the Activities by Acuity

Level document. (see Appendix 5)

At a minimum the Acuity Scale should be revised

as follows:

Level 4 – Every 3 months.

Level 1-3 – Every 6 months.

Section 5: Individualized Service Plan (ISP) The development of the ISP consists of the translation of information acquired during Intake

and/or completion of the acuity scale into short and long-term objectives for the maintenance and

independence of the client. The service plan includes: identification of all services currently

needed by the client; identification of agencies that have the capacity to provide needed services

to the client; specification of how the client will acquire those services; the procedure that will be

followed to assure the client has successfully procured needed services; and a plan for how the

various services the client receives will be coordinated while specifically defining the role of the

case manager. Client participation in the development of the service plan is encouraged to the

fullest extent possible. In particular, client feedback should be obtained on each element of the

service plan before it is implemented.

Every new or re-enrolling case management client must have an ISP completed and signed by

both the case manager and client. Additionally, there must be an ISP completed for every new

and re-certifying Ryan White Part B ADAP/HICP client at least every 6 months. If an

ADAP/HICP client already has a case manager, the same ISP can be utilized for the

ADAP/HICP client charts. Any client who only receives ADAP/HICP must be informed of the

additional services offered by the Ryan White Part B Program. If the client decides to decline

these additional services except for ADAP/HICP, the client must sign a Declination of Services

except ADAP/HICP form.

The primary goal of the ISP is to ensure clients access, retention, coordination of care and

follow-up, and medical/treatment adherence to primary medical care by removing barriers to

care. A medical, psychosocial and financial portrait of the client is created using information

gathered during the Intake and acuity scale process. The information is then utilized to develop a

mutually agreed upon comprehensive ISP with specific goals and action steps to address barriers

to care.



The ISP is the “bridge” from the assessment phase to the actual delivery of services and

constitutes another essential function of case management. It is developed on the basis of the

information obtained from the client assessment and pinpoints the individualized needs of the

client and links the appropriate services with the needs. The ISP is a map of actions that

documents the interventions, actions, responsibilities and timeframes needed to meet the

identified goals. Interventions and actions may be immediate, short term or future focused.

Future focused interventions anticipate a persons’ changing life circumstances and recognize the

role of prevention. The realistic needs of the client should be reflected in the development of the

plan. The ISP must include coordination and follow-up of medical treatments and treatment

adherence.

The client is involved with the planning of the ISP, but it is the responsibility of the case

manager to write the plan. The client’s primary physician, mental health provider, caregiver, and

other appropriate individuals should be contacted for additional information if deemed

appropriate. It is important that the case manager have a comprehensive knowledge of the

community resources to address the needs of the client during the development of the ISP.

ISP’s should be developed using SMART objectives; Specific, Measurable, Attainable,

Realistic, and Time Specific. Information documented on the ISP can be brief statements that

explain the client’s situation. The document contains a set of goals and activities that help clients

access and maintain access to services, particularly primary medical care, gain or maintain

medication adherence, and move towards self-sufficiency. Short term goals address immediate

needs, especially those required to stabilize the client or to deal with a crisis situation. These are

goals that the client can realize in the near future, such as in a day, within the week or even a few

months. Long term goals are achieved over a longer period of time. These goals are usually those

that are meaningful, thus giving the client a sense of greater importance. It is important to

prioritize goals and help clients decide what is most important right now. The ISP documents the

resources readily available to help the client make immediate improvements in his/her situation.

After completing the assessment, case managers should be able to answer basic questions about

the new client and his/her care needs. Information collected should be used as a baseline from

which to update the client’s health status and change in service needs over time. Both the case

manager and client must sign and date the ISP; however, agencies using EMRs may use an

electronic signature for case managers. Additionally, the client must be offered a copy of his/her

ISP and the ISP should be kept in the client’s chart.

Implementation requires the case manager and the client to work together to achieve the goals

and objectives of the ISP. Providing social support and encouragement to the client is as much a

part of implementation as the actual brokerage and coordination of services. In order to make the

ISP work, the case manager and client need to determine how much autonomy the client can

exercise on his/her own behalf and how much assistance he/she needs in order to acquire the

services. Implementation of the ISP includes careful documentation in the case notes of each

encounter with the client, dates of contact, information on who initiated contact and any action

that resulted from the contact should be included in the case notes.



When to revise the ISP

The ISP should be completed for all case managed clients. Level 4 clients should have an ISP

revised at least every 3 months and Level 1-3 revised at least every 6 months. The acuity scale

should be updated during this time as well. Upon revising the ISP, a case note must be

completed.

Case Managers must ensure that the following activities are completed for all new and

established Medical Case Management clients:

• All clients should have ISP goals established after initial assessment

• Develop a comprehensive ISP within 30 days of beginning the Intake

• Timely and coordinated access to medically appropriate levels of health and

support services and continuity of care


• Re-evaluation of the care plan at least every 3-6 months with adaptations as

necessary



• Treatment adherence counseling to ensure readiness for adherence to complex

HIV treatments

• Client-specific advocacy and/or review of utilization of services

• All clients should have documented evidence of coordination of services required

to implement the ISP during service provision, referrals, and follow-up

Case Managers must ensure that the following activities are completed for all new and

established Non-Medical Case Management clients:

• All clients should have ISP goals established after initial assessment

• Develop a comprehensive ISP within 30 days of beginning the Intake





necessary





Coordination of Care and Re-Evaluating ISP Coordination involves communication, information sharing, and collaborating, which can occur

regularly with case management and other agencies serving the client. The case manager and

agencies work together on a case-by-case basis to ensure that clients receive appropriate services

without duplication. During coordination of services the case manager will focus on the clients’

strength and accomplishments rather than focusing on short comings or relapses. Coordination

activities may include directly arranging access, reducing barriers to obtaining services,

establishing linkages, and other activities recorded in the case note.

Table 5. ISP Assessment

Standard Measure

5.1 Conduct client eligibility evaluation every 6

months. The process to determine client

eligibility must be completed in a time frame

so that services are not delayed.

Eligibility assessment must include at a minimum:

• Proof of income

• Proof of residency

• Proof of active participation in primary

care or documentation of the client’s plan

to access primary care.

5.2 All newly enrolled or reactivated case

managed clients must have an acuity scale and

comprehensive ISP completed within 15 days

for a Level 4 and 30 days for a Level 1-3 of

beginning the initial Intake

5.3 All newly enrolled or re-certifying

ADAP/HICP client must have an ISP

completed within 30 days of beginning the

application.

At minimum, the initial assessment should cover

the following areas:

• Medical History/Physical Health Status

• Medical Treatment and Adherence

• Health Insurance

• Family/Domestic Situation

• Housing Status

• Source of Income

• Nutrition/Food

• Mental Health

• Substance Abuse

• Personal and Community Support

Systems

• Disclosure

• Risk Reduction

• Legal Issues

• Transportation

• Cultural Beliefs and Practices/Languages

• Dental

• Emergency Financial Assistance

• Additional Service Needs

Ensure that documentation (case notes, initial

assessment, or re-assessment) is in the client’s

record.



Table 6. Coordination of Services Standard Measure 6.1 Implement client’s ISP. Documentation in client’s record of progress

toward resolution and outcome of each item in

client’s ISP.

6.2 Identify and communicate with other case

managers with whom the client may be

working with. Collaboratively determine with

all parties and the client the person most

appropriate to serve as the primary case

manager.

Documentation in client’s record of other case

managers with whom the client may be working

with and documentation of who is the most

appropriate person to serve as the primary case

manager.

6.3 With consent of the client, identify and

communicate with other service providers

with whom the client may be working. This

can occur during team meetings to coordinate

continuity of care.

Documentation of communication in client’s

record.

Agenda or meeting notes.

6.4 Coordination and follow-up of primary

medical care and treatment adherence. Clients

should have one visit with their primary care

provider (i.e., MD/DO, PA, and APRN) at

least every six (6) months. For clients who

have not had a visit with their primary care

provider, the case manager should follow-up

with the client within 30 days to determine

barriers to care and adherence.

Attendance at medical visits.

Documentation of referrals to primary care and

follow-up within 30 days.

Re-evaluating the ISP – The case manager must complete an assessment of the client’s needs in

accordance with the Activities by Acuity document. It is critical that the ISP be updated in

collaboration with the client, considering his/her priorities and perception of needs. The ISP

should be revised at least every 6 months, including any new goals identified and completed.

This includes a re-evaluation of health issues related to HIV and non-HIV, resources available to

a client, as well as compliance with treatment adherence. The case manager will ensure that

persons living with HIV/AIDS and not accessing or using primary medical care could still

receive other supportive services if desired. Access to other HIV supportive services is not

conditional upon access to, or use of primary medical care.



Table 7. Re-Evaluating the ISP Standard Measure 7.1 ISPs for medical and non-medical case

management clients should ensure that all

areas of assessment have been completed and

updated in accordance with the Activities by

Acuity Level document.

7.2 ISPs for ADAP and HICP clients should

ensure that all areas of assessment have been

addressed and updated at least every 6

months.

At minimum, the assessment should cover the

following areas:

• Medical History/Physical Health Status

• Medical Treatment and Adherence

• Health Insurance

• Family/Domestic Situation

• Housing Status

• Source of Income

• Nutrition/Food

• Mental Health

• Substance Abuse

• Personal and Community Support Systems

• Disclosure

• Risk Reduction

• Legal Issues

• Transportation

• Cultural Beliefs and Practices/Languages

• Dental

• Emergency Financial Assistance

• Additional Service Needs

Ensure that documentation (case notes, initial

assessment, or re-assessment) is in the client’s

record.

7.3 All medical and non-medical case

management clients must have an Acuity

Scale and ISP revised in accordance to the

Activities by Acuity Level document.

The following information must be provided for

each area assessed on the ISP: Identified Needs,

Goals, Interventions/Timelines, and Outcomes.

Documentation (case notes, initial assessment, or

re-assessment) in client’s record.

Termination of Case Management Services/Discharge Planning is an important component

of medical and non-medical case management. There are legitimate reasons for terminating

medical case management services with a client, but keep in mind that termination should never

be assumed. A good faith effort must be attempted and clearly documented in the client’s chart

prior to discharge from case management. For example, clients may be very difficult to locate for

numerous reasons, such as recent incarceration, extended hospitalization, homelessness or in

transition.



Table 8. Transition and Discharge

Standard Measure

8.1 Discharge a client from case management

services if any of the following conditions

apply:

• Client is deceased

• Client requests discharge

• Client’s needs change and they would be

better served through primary case

management at another provider agency

• If a client’s actions put the agency, case

manager, or other clients at risk (i.e.,

terrorist threats, threatening or violent

behavior, obscenities, harassment or

stalking behavior).

• If client moves/re-locates out of service

area

• If after repeated and documented

attempts, a case manager is unable to

reach a client for twelve (12) months.

• If the client no longer meets Ryan White

eligibility requirements.

Documentation exists in client’s record of reason

for discharge.

Section 6: Documentation

Documentation is a key means of communication among interdisciplinary team members. It

contributes to a better understanding of a client and his/her family/caregiver’s unique needs and

allows for interdisciplinary service delivery to address those needs while reflecting the

accountability and involvement of the case manager.

Documentation is an important process that facilitates and explains what services were provided

and what actions were taken. Good documentation will facilitate communication between service

providers and ensure coordinated, rather than fragmented service provision. It is important to be

able to provide relevant client information at any given time. This is necessary for the legal

protection of both the agency and the case manager. Remember “if it’s not documented, it never

happened”. Documentation runs concurrently throughout the entire case management process

and should be concise, accurate, up-to-date, meaningful, and consistent. The following

information should be documented: history and needs of a client; any services that were

rendered; outcomes achieved or not achieved during periodic reviews; and any additional

information (e.g. case conferences, email exchanges, consultation with others, and any additional

exchanges regarding the client). Case note documentation should be complete so anyone reading

the case notes can understand who this client is, what brought them to the office, what goals

were established, what is the plan, what interventions were used, and what referral/follow-up

will happen, if any. It is also useful to record contact and other details of agencies used, such as

phone numbers and contact names of an interpreter service, or the hours of availability of a

service provider for future reference. Language in case notes needs to be strengths based.



Documentation must ensure that the following activities are being completed for all new and

established case management clients:

New

• Standardized Case Management Intake

• Acuity Scale

• Acuity Scale completed and leveled in accordance with the Activities by Acuity

Level document

• ISP

• Case note

Established clients

• Acuity Scale updated every 3-6 months and leveled in accordance with the

Activities by Acuity Level document

• The ISP updated every 3-6 months and leveled in accordance with the Activities

by Acuity Level document

• Case notes documented in client’s chart, in accordance with the Activities by

Acuity Level document

In an effort to standardize documentation and be in alignment with federal guidelines, all case

note documentation must be reflective of how healthcare outcomes are being improved as well as

how providing guidance and assistance is improving access to services for clients. In 2017, the

Georgia Ryan White Part B program adopted two standardized formats for documenting

case notes for charting: 1) APIE (Assessment, Plan, Intervention, and Evaluation); and 2)

SOAP notes (Subjective, Objective, Assessment, and Plan). Medical and Non-Medical Case

Management services are provided by both case managers and nurse case managers. The nurse

case manager is often functions in a dual capacity as both nurse and case manager, which means

he/she is also expected to be in compliance with Georgia Case Management Standards during

service provision.

The case manager will have the option of using an APIE or SOAP note format. nurse case

managers can continue to use the SOAP note format for documentation in client charts. APIE is

a format that condenses client statements by combining subjective and objective information into

the Assessment section and combining actions with the expected outcomes of client care into the

Plan component. The four phases of APIE are:

• Assessment: information about the client’s presenting issues, gathering of the

facts, some historical perspective, and assessment of the client’s needs

• Plan: a plan is developed in order to address the identified need of the client

• Implementation: specific tasks or action steps that need to be taken in order to

fulfill the plan

• Evaluation: provides a means for accountability in ensuring that the plan is being

worked on and progress is updated. It should include timelines and specific

measurable outcomes



A SOAP note is another documentation format used to document in a client’s chart. The four

parts of SOAP note documentation are:

• Subjective: describes the client’s perception of their condition in narrative form

• Objective: documents your perception of the client’s physical state or status

• Assessment: details the assessment or presenting reason for the visit

• Plan: describes the plan for managing the client’s concern/condition

The strength of case management services provided depends on good documentation in the

client’s records. Charts should include:

• Important enrollment forms and information such as Intake forms, consent for

enrollment forms, release of information forms, etc.

• Client information used to develop the initial assessment and the individualized

service plan (ISP), monitoring activities, and revisions to the ISP

• Medical information and service provider information, and confirmation of

diagnosis

• Benefits/entitlement counseling and referral services provided. Documentation

should include assistance in obtaining access to both public and private programs,

such as but not limited to, Medicaid, Medicare Part D, Patient Assistance

Programs (PAP), co-pay cards, AIDS Drug Assistance Programs (ADAP), other

state and local healthcare documents and supportive services

• The nature, content, units of case management services provided and whether the

goals specified in the care plan have been achieved

• Whether the client has declined services at any time while being an active client

in case management

• Timelines for providing services and re-evaluations

• Clear documentation of the need and coordination with case managers of other

programs

• Entries should be documented in chronological order. Do not skip lines or leave

spaces

• Be specific, use time frames, and quotations if indicated. Avoid generalizations

with documentation

• Avoid labeling or judging a client, family, or visitor in the documentation

• Use a problem oriented approach: identify the problem, state what was done to

solve it, and document any follow-up instructions including timelines as well as

the outcome

• Document all interactions with the client, outside organizations and other

consulting disciplines

General Documentation Principles

Follow general documentation principles including:

• Document in ink only

• Record the client’s name and identifiers (e.g., date of birth or clinic ID number)

on every page

• Record date on all entries

• Document the duration of the encounter (i.e., 15 minutes, 30 minutes, 1 hour etc.)



• Ensure the type of encounter is identified (face-to-face, telephone contact,

consult, etc.)

• Personnel must sign all entries with full name and professional title.

• Ensure that entries are legible

• All entries should be made in a timely manner (i.e., the same day). Late entries

should be clearly indicated as such

• If an error is made, then make one strike through, initial and date the error, do not

use white out under any circumstances

• Thoroughly complete all forms, applications, and other documents with the most

accurate information available

• Do not alter forms, applications, or other documents

• Do not forge signatures (i.e., do not sign for the provider (MD/DO, APRN, PA),

client, etc.)

Note: Submission of incomplete, inaccurate, or altered applications may result in delays in client

services. Submission of incomplete ADAP applications will result in the delay of medications to

the client.

Table 9. Documentation

Standard Measure

9.1 Each agency must have a documentation

policy.


9.2 Case managers must participate in

documentation training.

Training records in personnel file.

9.3 Case managers must ensure that appropriate

signatures are on all applicable documents.

Documents maintained in the client’s charts.

9.4 Case managers must document all interactions

or collaborations which occurred on client’s

behalf.

Documents maintained in the client’s charts.

9.5 Each client’s case management record must be

complete and include all relevant forms and

documentation.

Client chart contains all relevant forms, proof of

eligibility, ISP, case notes, and other pertinent

documents.



Appendix A



Appendix B



Appendix C



Appendix D



Appendix E



Appendix F



Appendix G



Georgia Department of Public Health Division of Health Protection

Office of HIV/AIDS

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